Table 5 Breakdown of statements of recommendations, its individual rank by experts’ opinion and level of agreement

Recommendations of management

1.1. Start with csDMARDs at an early stage, with methotrexate in the dose of 15–25 mg/week preferred in those with relevant skin involvement for first-line treatment, MTX can be given orally, subcutaneous or Intramuscular route. Shared decision-making is advisable to agree which methotrexate administration form is preferable (oral vs subcutaneous vs intramuscular). Methotrexate should be taken for 12 weeks to judge the patient response to treatment. (LE:1 .GOR: A)

1.2. In patients with a contraindication to MTX or show intolerance; other csDMARDs including sulfasalazine, leflunamide, cyclosporine should be considered as first line of treatment strategy(LE: 1.GOR: A )

1.3. Methotrexate has been shown to increase the risk of developing liver fibrosis in patients with psoriasis, and should be used with caution in obese patients, patients who consume alcohol, and patients with other risk factors for hepatotoxicity such as diabetes and hepatitis. (LE:1 .GOR: A)

1.4. If biological therapy is not available; offer another cDMARDs (methotrexate, leflunomide, sulfasalazine, or cyclosporine) or in combination in a step-up strategy when the treatment target (remission or low disease activity) has not been achieved despite dose escalation within 3 months. (LE:4 .GOR: C )

1.5. Significant improvement [detected by PsA response criteria (PsARC) using tender and swollen joint count and patient and physician global assessment.] using csDMARDs should be achieved by 3 months. If no significant improvement has been achieved, by 3 months, adding another DMARD to MTX or use a different combination DMARD therapy is advised. DMARDs doses should be optimized to the maximum tolerable licensed levels (LE: 3.GOR: C)

1.6. Combined DMARD therapy means: MTX + SSZ, MTX + CSP, SSZ + CSP, or MTX + LEF (LE: 4 .GOR: C).

1.7. Consider oral non-steroidal anti-inflammatory drugs (NSAIDs, including traditional NSAIDs and cox II selective inhibitors), when control of pain or stiffness is inadequate. Take account of potential gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age and pregnancy. (LE: 4 .GOR: D).

1.8. When using oral NSAIDs: (LE:1.GOR: A)

• Offer the lowest effective dose for the shortest possible time

• Offer a proton pump inhibitor (PPI)

• Review risk factors for adverse events regularly.

1.9. Local glucocorticoid injections should be considered when there is resisted oligo or monoarthritis. (LE:1 .GOR:A )

1.10. If the treatment target not achieved after 3 months of csDMARD therapy; switching to a bDMARD should be considered with or without MTX. (LE: 1.GOR: A)

1.11. Starting biological therapy from the first may be considered in severe cases (PASDAS score ≥ 5.4) with poor prognostic factors (LE: 2.GOR: B)

1.12. The cut-off point of starting biologic therapy is moderate Disease Activity: PASDAS: 3.2 to 5.4, and associated with adverse/poor prognostic factors (> 5 active joints, radiographic damage, elevated acute phase reactants, extra-articular manifestations especially dactylitis) functional disability (HAQ or equivalent) score > 2, US Doppler activity > 2 in > 3 joints. (LE: 5 .GOR: D)

1.13. First line biologic therapy: Use TNF-inhibitors, IL-17 inhibitor, IL-12/23 inhibitor, IL-23 inhibitor, CTLA4-ig, JAK inhibitor, or PDE4 inhibitor (IL-17 inhibitor, IL-12/23 inhibitor, or IL-23 inhibitor are advised/preferable if extensive skin affection identified by PASI score). (LE: 1.GOR: A)

1.14. Significant improvement (i.e., reaching minimal disease activity MDI, or low disease activity PASDAS: 1.9–3.2) using bDMARDs should be achieved by 3 months and the target should be achieved by 6 months. Treatment should be continued only if there is an adequate response at 6 months following initiation of therapy. (LE: 3.GOR: C)

1.15. If the patient has an inadequate initial response not reach even minimal disease activity (primary failure), switch out of therapeutic class considering a drug with other working mechanism is advised. (LE: 3.GOR: C)

1.16. In case of secondary failure to anti-TNF agent initially verify if the symptoms are due to active disease and confirm compliance. If verified, therapeutic drug monitoring is advised. In case of low drug levels with high antibodies, switching to another anti-TNF. However, if there is adequate drug level, no antibodies, it is advisable to switch out of the therapeutic class. (LE: 3.GOR: C)

1.17. In patients with persistent active disease, a tsDMARD, such as tofacitinib and PDE4-inhibitor (apremilast), should be considered. (LE: 3.GOR: C)

1.18. Treatment should normally be initiated with the least expensive drug (taking into account administration costs, required dose and product price per dose). This may need to be varied in individual cases due to differences in the mode of administration and treatment schedules. (LE: 5.GOR: D)

1.19. When switching from an anti-TNF drug (originator) to a biosimilar of that originator, one has to take into consideration that antidrug antibodies against the originator will cross-react with the biosimilar, causing treatment failure (LE:4 .GOR: D)

1.20. Non-pharmacological management (LE:4 .GOR: D)

• Physiotherapy: adults with PsA should have access to specialist physiatrist, with periodic review to: improve general fitness and encourage regular exercise, learn about the short-term pain relief provided by methods such as transcutaneous electrical nerve stimulators (TENS).

• Psychological interventions: offer psychological interventions (for example, relaxation, stress management, and cognitive coping skills) to help adults with PSA adjust to living with their condition.

• Diet therapy: Patients could be encouraged to follow the principles of a Mediterranean diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils, and it may be of value in management metabolic comorbidities.